Document Type : Original Article(s)
Authors
1 Department of Midwifery, School of Nursing and Midwifery, Reproductive Sciences and Sexual Health Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Epidemiology and Biostatistics, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
3 Reproductive Sciences and Sexual Health Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
Abstract
Background: Pregnancy and the transition to parenthood are periods in parents’ lives that require tremendous adjustment. The physical and mental health of mothers during these periods is significantly associated with maternal acceptance. The present study aimed to evaluate the correlation between intimate partner violence (IPV) during pregnancy and parental acceptance by primiparous mothers in Isfahan, Iran.
Methods: A cross-sectional descriptive and correlational study was conducted from September 2021 to February 2022 in Isfahan, Iran. The target population was primiparous mothers in the postpartum period referred to nine different health centers across Isfahan. The participants (n=308) completed three questionnaires, namely demographic, Tabrizi intimate partner violence screening, and parental acceptance questionnaire. Data were analyzed using descriptive and inferential statistics with SPSS software (version 22.0). P<0.05 was considered statistically significant.
Results: The mean score of total IPV was 40.45±28.94. Domestic violence during pregnancy was reported by 59 (19.2%) mothers. The most common types were psychological violence (74.4%), followed by financial abuse (35.1%), sexual violence (17.2%), and physical violence (14.9%). The mean score of parental acceptance was 115.77±12.58. There was a significant inverse correlation between parental acceptance and IPV score (r=-0.15, P=0.005). The number of siblings and birth order had a significant inverse correlation with parental acceptance (r=-0.13, P=0.002; r=-0.13, P=0.002, respectively). Moreover, the age difference between the mothers and their next siblings had a significant direct correlation with parental acceptance (r=0.12, P=0.003).
Conclusion: Primiparous mothers subjected to IPV during pregnancy had lower parental acceptance after delivery.
Highlights
Masomah Jalili (Google Scholar)
Fatemeh Torabi (Google Scholar)
Keywords
What’s Known
Intimate partner violence (IPV) during pregnancy is a predictive factor for maternal mortality and morbidity. Maternal acceptance is a process that begins during pregnancy and can ultimately affect the child’s mental health.
What’s New
IPV is inversely correlated with parental acceptance. The mean score of parental acceptance in primiparous mothers was notably high, indicating that most Iranian mothers fully understand and accept their maternal responsibility.
Introduction
Pregnancy and the transition to parenthood are major periods of adjustment that have a significant impact on the lives of the new parents, the relationship quality of couples, and the development of the infant. 1 Motherhood begins from the moment of pregnancy and involves acceptance of pregnancy and fetus, and focuses on the process of becoming a mother. 2 Parental acceptance is defined as the expression of warmth, love, care, comfort, nourishment, and support from parents to their children, which can be in the form of physical (e.g., cuddles), verbal (e.g., praise), or other cultural-specific behaviors. 3 It is wrongly assumed that mothering is a natural process, 4 whereas developing a parent-child relationship takes time and effort. Transitioning to motherhood can be a stressful experience as it involves various challenges, including role change, chronic fatigue, family preferences and potential conflicts, financial pressure, and work-life balance. Although certain improvement in marital relationship has been reported, new parents may experience a decline in marital satisfaction and personal well-being. 5 In extreme cases, this may involve physical and psychological violence against mothers. 6
There are reports of a significant increase in the number of intimate partner violence (IPV) during pregnancy. However, some other studies reported a reduction in the occurrence of IPV. According to the World Health Organization, globally, approximately 30% of women have experienced IPV in their lifetime, and the prevalence among pregnant women ranges from 1% to 28%. 7 A previous study reported a prevalence of 25% for domestic violence against women during pregnancy, with the highest and lowest prevalence in African and European countries, respectively. 8 In Iran, the reported overall prevalence of domestic violence against pregnant women is 48%, the majority of which is in the form of psychosocial violence. 9 Domestic violence during pregnancy is associated with an increased risk of cesarean section, preterm labor, emotional distress, and postpartum depression. Furthermore, consequences for the fetus include small for gestational age, intrauterine growth restriction, and ultimately low birthweight. Some studies reported cigarette smoking and alcohol/substance abuse may increase the likelihood of IPV. 10 - 12
It has been reported that children who witness domestic violence during their childhood are more likely to display violent behavior against their partners during adulthood. 13 Patriarchy is also reported as a contributing factor for the dominance of men over women, exacerbated by women’s submission to accept domestic violence as a cultural norm. 14 A previous study suggested that patriarchy in Ghana has legitimized that decision-making is reserved exclusively for men, and domestic violence against women is endorsed as a means of maintaining order at home. 15
Mothering styles in the context of IPV have been classified as compensatory or deficit parenting responses. The compensatory response is defined as the display of a supportive and sustained positive parenting style. Whereas, the majority of mothers subjected to IPV display a deficit response and negative parenting style. 16 Examples include intentional harm to the fetus or physical abuse and neglect of children and infants. 17 Overall, IPV negatively affects parent-child interaction and parental affection, which in turn results in increased aggressive behavior in children. 18 , 19 Mothers subjected to IPV experience less prenatal bonding, may have problems accepting motherhood, and their children are susceptible to more behavioral disorders. 20 , 21 All of these ultimately undermine a mother’s ability to fulfill the child’s needs. 22
Given the above, the present study aimed to evaluate the correlation between IPV during pregnancy and parental acceptance by primiparous mothers in Isfahan (Iran).
Materials and Methods
A cross-sectional descriptive and correlational study was conducted from September 2021 to February 2022 at the Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran. The study was approved by the Ethics Committee of Isfahan University of Medical Sciences (code: IR.MUI.NUREMA.REC.1400.067).
The target population was primiparous mothers in the postpartum period referred to different health centers across the city of Isfahan. Initially, the city was divided into nine geographic areas, from which one health center per area was randomly selected. In accordance with a previous study, 23 the sample size was calculated based on the formula below.
Total sample size: N=[(Zα+Zβ)/C]2+3
Zα: Standard normal deviate for α (0.05), Zβ: Standard normal deviate for β (0.1), and C=0.5×ln[(1+r)/(1-r)] where r is the expected correlation coefficient (0.2).
Accordingly, a sample size of a minimum of 265 was calculated. However, considering attrition probability, a total of 342 primiparous mothers were selected. The inclusion criteria were Iranian nationality, literacy, willingness to participate in the study, cohabitation with the husband; and no history of infertility, severe mental health problems (e.g., depression), drug abuse and addiction, or the use of psychotropic substances. The exclusion criteria were unwillingness to participate in or continue with the study, hospitalization of the infant for any reason, and having an infant with a major congenital anomaly.
Initially, the participants were informed about the objectives of the study, and confidentiality of the provided information was guaranteed. Subsequently, written informed consent was obtained from all participants. The participants were requested to complete three questionnaires, namely a demographic questionnaire, Tabrizi intimate partner violence screening questionnaire, 24 and a parental acceptance questionnaire (figure 1). Of the initial 342 selected primiparous mothers, 18 withdrew from the study, and 16 did not complete the questionnaires. Of the remaining 308 primiparous mothers, 18 appeared to have experienced severe IPV and thus referred to a psychologist for counseling. Of these, 15 primiparous mothers were systematically followed up as their problems required further therapy.
Figure 1. Schematics of the study process.
Instruments
Demographic Questionnaire: A dedicated 14-item questionnaire was developed to establish the demographic characteristics of the participants. Collected information included age, cohabiting status, years of marriage, gravida, number of abortions/siblings, birth order, education, and occupation. The validity of the questionnaire was verified by senior academic staff at Isfahan University of Medical Sciences (Isfahan, Iran).
Tabrizi Intimate Partner Violence Screening: A 61-item IPV questionnaire was used to measure the frequency and circumstances of violence committed by the husband in the past year. The questionnaire is scored using a five-point Likert scale with a total score ranging from zero to 244. The reliability of the total questionnaire and each item was confirmed with a Cronbach’s alpha coefficient of 0.81. 24
Parental Acceptance Questionnaire: A previously designed 30-item questionnaire was adapted by reviewing relevant literature and published research articles. 25 , 26 The questionnaire is scored on a five-point Likert scale with a total score ranging from 30 to 150. Higher scores indicate more acceptance. Face and content validity were assessed based on the Lawshe method, 27 i.e., the opinion of a 10-member expert panel. The content validity ratio of the questionnaire was 0.7, and the content validity index was 0.89. The reliability of the questionnaire using test-retest was 0.93 with Cronbach’s alpha coefficient of 0.87.
Statistical Analysis
Data were analyzed using SPSS software, version 22.0 (IBM Corp., Armonk, NY, USA). The analysis method included descriptive and inferential statistics, as well as Spearman’s correlation coefficient, Mann-Whitney, and Kruskal-Wallis tests.
Results
The mean age of the 308 primiparous mothers was 28.90±4.90 years. The majority of these mothers had an undergraduate degree (43.5%). However, 239 (77.6%) of them were housewives. Most of the husbands had a high school diploma (33.4%), and 182 (59.1%) were self-employed (table 1).
| Parameters | Data (n, %) | |
|---|---|---|
| Age gap with husband | Younger | 266 (86.4%) |
| Older | 25 (8.1%) | |
| Same age | 17 (5.5%) | |
| Number of previous marriages | None | 297 (96.4%) |
| One or more | 11 (3.6%) | |
| Living with her/her husband’s family | Yes | 70 (22.7%) |
| No | 238 (77.3%) | |
| Years of marriage | <1 | 19 (6.2%) |
| 1-3 | 100 (32.5%) | |
| 4-5 | 74 (24%) | |
| >6 | 115 (37.3%) | |
| Mother’s education | Elementary school | 14 (4.5%) |
| Junior school | 19 (6.2%) | |
| High school | 66 (21.4%) | |
| Higher Diploma | 34 (11%) | |
| Undergraduate degree | 134 (43.5%) | |
| Postgraduate degree | 41 (13.3%) | |
| Husband’s education | Elementary school | 21 (6.8%) |
| Junior school | 27 (8.8%) | |
| High school | 103 (33.4%) | |
| Higher Diploma | 25 (8.1%) | |
| Undergraduate degree | 91 (29.5%) | |
| Postgraduate degree | 41 (13.3%) | |
| Mother’s occupation | Employee | 31 (10.1%) |
| Blue-collar worker | 5 (1.6%) | |
| Self-employed | 33 (10.7%) | |
| Housewife | 239 (77.6%) | |
| Husband’s occupation | Employee | 70 (22.7%) |
| Blue-collar worker | 46 (14.9%) | |
| Self-employed | 182 (59.1%) | |
| Unemployed | 10 93.2%) | |
| Gravida | 1 | 240 (77.9%) |
| 2 | 59 (19.2%) | |
| 3 | 7 (2.3%) | |
| 4 | 2 (0.6%) | |
| Number of abortions | None | 240 (77.9%) |
| 1 | 59 (19.2%) | |
| 2 | 7 (2.3%) | |
| 3 | 2 (0.6%) | |
| Number of siblings | None | 6 (1.9%) |
| 1 | 61 (19.8%) | |
| 2 | 80 (26%) | |
| 3 | 51 (16.6%) | |
| 4 | 39 (12.7%) | |
| ≥5 | 71 (23%) | |
| Birth order | First | 89 (28.9%) |
| Second | 80 (26%) | |
| Third | 47 (15.3%) | |
| Fourth | 36 (11.7%) | |
| Fifth and more | 56 (18.1%) | |
The mean score of total IPV was 40.45±28.94 (table 2). Domestic violence during pregnancy was reported by 59 (19.2%) mothers. Psychological violence during pregnancy was reported by 229 (74.4%) mothers, followed by financial abuse by 108 (35.1%), sexual violence by 53 (17.2%), and physical violence by 46 (14.9%).
| Variables* | Mean±SD | Range |
|---|---|---|
| Total intimate partner violence | 40.45±28.94 | 0-179 |
| Psychological violence | 4.49±5.73 | 0-44 |
| Financial abuse | 1.26±2.52 | 0-20 |
| Sexual violence | 0.47±1.47 | 0-16 |
| Physical violence | 0.62±2.44 | 0-24 |
| Patriarchal beliefs | 30.19±22.79 | 0-100 |
| Learning violence | 3.40±4.35 | 0-21 |
| *Descriptive and inferential statistics | ||
The mean score of parental acceptance by mothers was 115.77±12.58. In terms of accepting maternal responsibility, 98 (31.8%) were not fully ready to accept the role, whereas 210 (68.2%) understood and accepted the responsibility. The results of Spearman’s correlation coefficient showed an inverse correlation between parental acceptance and IPV score (r=-0.15, P=0.005), psychological violence (r=-0.16, P=0.004), financial abuse (r=-0.15, P=0.007), sexual violence (r=-0.13, P=0.019), and physical violence (r=-0.21, P<0.001) (table 3). Correlations of quantitative and qualitative demographic variables with parental acceptance are presented in tables 4 and 5.
| Intimate partner violence* | Parental acceptance | |
|---|---|---|
| r | P value | |
| Total intimate partner violence | -0.15 | 0.005 |
| Psychological violence | -0.16 | 0.004 |
| Financial abuse | -0.15 | 0.007 |
| Sexual violence | -0.13 | 0.019 |
| Physical violence | -0.21 | <0.001 |
| *Spearman’s correlation coefficient; Statistical significance at P<0.05. | ||
| Variables | Parental acceptance | ||
|---|---|---|---|
| Mean±SD | r | P value | |
| Age* | 28.90±4.90 | 0.01 | 0.80 |
| Number of siblings* | 3.17±2.06 | -0.13 | 0.02 |
| Birth order* | 2.88±1.99 | -0.13 | 0.02 |
| Age difference with the next sibling* | 2.90±3.17 | 0.12 | 0.03 |
| Gravida* | 1.26±0.52 | 0.97 | 0.18 |
| Number of abortions | 0.26±0.52 | 0.97 | 0.18 |
| *Spearman’s correlation coefficient; Statistical significance at P<0.05. | |||
| Maternal characteristics | Q1 | Q2 | Q3 | P value | |
|---|---|---|---|---|---|
| Age difference with husband* | Younger | 107 | 118 | 124.75 | 0.39 |
| Older | 109 | 119 | 125 | ||
| Same age | 104.5 | 114 | 120.5 | ||
| Number of previous marriages** | None | 107 | 117 | 124 | 0.10 |
| One or more | 115 | 120 | 131 | ||
| Living with her/husband’s family** | Yes | 106 | 118 | 125.5 | 0.81 |
| No | 107 | 117 | 124 | ||
| Years of marriage* | <1 | 102 | 111 | 131 | 0.86 |
| 1-3 | 108 | 117 | 124 | ||
| 4-5 | 107.5 | 118 | 123 | ||
| ≥6 | 106 | 118 | 123 | ||
| Mother’s education* | Elementary school | 101 | 113.5 | 123 | 0.63 |
| Junior school | 102 | 106.5 | 130.5 | ||
| High school | 106.75 | 118 | 123 | ||
| Higher Diploma | 106.5 | 118 | 123.5 | ||
| Undergraduate degree | 108 | 119 | 125.5 | ||
| Postgraduate degree | 105.5 | 115 | 125 | ||
| Husband’s education* | Elementary school | 103 | 111 | 118 | 0.22 |
| Junior school | 106 | 122 | 131 | ||
| High school | 107 | 118 | 123 | ||
| Higher Diploma | 113 | 120 | 126 | ||
| Undergraduate degree | 108 | 117 | 124 | ||
| Postgraduate degree | 105.5 | 117 | 125 | ||
| Mother’s occupation* | Employee | 108 | 116 | 124 | 0.08 |
| Blue-collar worker | 95 | 100 | 114.5 | ||
| Self-employed | 100.5 | 116 | 122 | ||
| Housewife | 108 | 118 | 125.5 | ||
| Husband’s occupation* | Employee | 108 | 115.5 | 122.25 | 0.14 |
| Blue-collar worker | 102 | 112 | 122 | ||
| Self-employed | 108 | 120 | 126.5 | ||
| Unemployed | 95 | 114.5 | 120.5 | ||
| *Kruskal-Wallis test; **Mann-Whitney test; Statistical significance at P<0.05. Q: Quartile | |||||
Discussion
The results showed that 19.2% of the mothers experienced domestic violence during pregnancy. In contrast, the reported rates in Mashhad (Iran) and India were 54% and 1-9%, respectively. 21 , 28 The most common type of violence in our study was psychological violence (74.4%), whereas in Egypt, domestic violence was prominent (50.80%) followed by psychological violence (45.40%). 29 Compared to other studies, the rate of IPV during pregnancy was lower than expected. However, the rate was comparable to the results of a meta-analysis (1-28%). 7 Overall, the reported prevalence of IPV during pregnancy varies depending on the geographical area and the context. However, pregnancy seems to be a contributing factor to IPV. 7 , 21 , 28 , 29
The mean score of parental acceptance was higher than expected, indicating that most Iranian mothers in this study were aware of and accepted maternal responsibilities. This is in line with the findings of a previous study that stated Iranian women culturally viewed motherhood as their prime responsibility, an important part of their identity, and their obligation to future generations. 4 As in another study, 20 we found an inverse correlation between IPV and parental acceptance (r=-0.15, P=0.005), i.e., as domestic violence increased, the parental acceptance score decreased, and, as a result, more behavioral disorders occurred in children. Holmes reported a positive association between IPV and poor maternal warmth, leading to frequent physical and psychological abuse of children. 19 Despite the negative impact of IPV against mothers, most mothers are willing to go the extra mile to fulfill their maternal responsibility and provide extra care (i.e., maternal acceptance). 30 , 31 Pregnancy is a critical period of adjustment to parental acceptance, which is influenced by internal and external stressors. Our results showed the negative effect of IPV during pregnancy on maternal mental health, and subsequently maternal acceptance. In contrast, some studies reported no association between IPV and maternal acceptance. For example, a study concluded that breastfeeding (a parenting behavior) did not differ in women with or without a history of domestic violence. 32
The results of the present study showed a significant inverse correlation between parental acceptance and demographic variables such as the number of siblings and birth order (r=-0.13, P=0.002; r=-0.13, P=0.002, respectively). Our results were in line with a previous study in Turkey reporting an inverse correlation between the number of siblings and parental acceptance. 33 Variables such as age difference between the mother and her next sibling had a significant direct correlation with parental acceptance (r=0.12, P=0.003). Age, age gap with husband, number of previous marriages, mothers living with their family or husband’s family, years of marriage, and education/occupation of either the mother or husband had no correlation with parental acceptance. Shrooti and colleagues also reported no correlation between the mother’s education and parental acceptance. 34 However, another study showed that the more years of education, the less permissive the mother’s parenting style was and the better the parental acceptance. 35
Conclusion
A substantial percentage of primiparous mothers subjected to IPV during pregnancy have lower parental acceptance after delivery. Therefore, IPV screening of women during pregnancy and post-delivery counseling is strongly recommended. Parental acceptance should be assessed as an independent factor during preconception counseling and as part of perinatal care. Future studies should develop a comprehensive care and social support plan for mothers subjected to IPV and domestic violence, and compare the maternal acceptance levels.
Acknowledgment
The present manuscript was extracted from the Master’s thesis by M. Jalili. The study was approved by the Reproductive Sciences and Sexual Health Research Center, Isfahan University of Medical Sciences (project number: 3400247). The authors would like to thank the mothers for their participation in the study.
Authors’ Contribution
M.J: Literature search, data acquisition, and analysis. MJ.T: Data acquisition and analysis. F.T: Literature search and data analysis. All authors have contributed to the study design, as well as drafting and revising the manuscript. They all have read and approved the final manuscript and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Conflict of Interest:
None declared.
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